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Based on record review and interview, the facility failed to ensure a medical history and physical examination was completed on admission in 1 of 10 medical records (Patient # 4) in a total of 10 medical records reviewed.

Findings include:

Record review of "101.04 Medical Staff Bylaws," #10394694, last revised 09/2021 on page 44 #7 revealed "Every patient shall be screened upon admission" and a "physical examination shall be accomplished in all cases... within 24 hours of the patient's admission."

Record review of policy "Documentation Guidelines" #10700859, last revised 11/2021, under Medical Services revealed "The Admission Note... shall be recorded in the Medical Record within 24 hours of admission."

Patient #9's medical record was reviewed and revealed Patient #9 was a 16-year-old admitted 1/20/2022 on a Chapter 51 hold (involuntarily hold for medical treatment) for aggressive behavior, exacerbated psychosis, and non-adherence to medical treatment. Admission history and physical was dated 1/27/2022 at 3:40 PM (7 days after admission). Patient #9 was discharged 1/31/2022.

On 5/05/22 at 12:10 PM during an interview with Health Information Supervisor N, when asked when a medical screening assessment should have been done on Patient #4, N stated the policy states 24 hours, "they dropped the ball on that one."

Based on record review and interview, the facility failed to ensure a physician assistant was supervised by a physician or designated LIP (licensed independent practitioner) on discharge in 1 of 3 patients whose discharge summary was completed by a physician assistant (Patient #1), in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Documentation Guidelines" #10700859, last revised 11/2021, page 12 under Discharge Summary revealed the "attending physician and /or designated LIP (licensed independent practitioner) shall be responsible for preparing... a discharge summary within 30 days of discharge."

Record review of "101.04 Medical Staff Bylaws," #10394694, last revised 09/2021 on page 49 under Allied Health Professionals - Independent revealed "Independent Allied Health Professionals covered under the Medical Staff Bylaws currently consists of Advanced Practice Nurse Prescribers." 'The ByLaws do not indicate that Physician Assistants are independent practitioners.

Review of Patient #1's medical record revealed Patient #1 was a 28-year-old brought in by the police 1/27/2022 and and admitted on a Chapter 51 hold (involuntary admission) for adjustment of his medications as he "expressed that the voices he is hearing are telling him to harm himself." He was treated and discharged 2/08/2022. The discharge summary was completed by Physician Assistant Q on 3/11/2022 at 4:34 PM. There was no evidence documented that it was reviewed by an attending physician or designated LIP.

On 5/05/2022 at 8:20 AM during interview with Medical Director J, Director J stated they have medical and psychiatric providers, physician assistants (PA), and advanced practice nurse prescribers (APNP) who are all credentialled and privileged every 2 years. Director J stated that physician assistant's can complete the discharge summary but they need a co-signature by a psychiatrist, medical doctor, or doctor of orthopathic medicine (DO).

On 5/05/2022 at 9:58 AM during interview with Physician Assistant (PA) Q, when asked if her/his discharge summaries need to be co-signed by a physician or a DO (doctor of orthopathic medicine), PA Q stated "I don't think so" they used to be, but that "went away."

Based on record review and interview, the facility failed to ensure the discharge summary included a baseline of the psychiatric, physical and social functioning of the patient at the time of discharge in 2 of 7 patient discharge summaries reviewed (Patients #1 , #8) in a total of 10 medical records reviewed.

Findings include:

Record review of "101.04 Medical Staff Bylaws," #10394694, last revised 09/2021 on page 44, #8 revealed " The medical record shall include... condition at discharge."

Record review of policy "Documentation Guidelines" #10700859, last revised 11/2021, page 12 under Discharge Summary revealed the "attending physician and /or designated LIP (licensed independent practitioner) shall be responsible for preparing... a discharge summary within 30 days of discharge... The Discharge Summary must include... Final Assessment of the Patient... and condition upon discharge."

Review of Patient #1's medical record revealed Patient #1 was admitted 10/04/2021 under a Chapter 51 hold (involuntary admission) for medication adjustment as he expressed" that the voices he is hearing are telling him to harm himself" . He was treated and discharged on 10/19/2022. His discharge summary was dated 10/21/2021 at 3:11 PM and cosigned on 10/28/2021 at 4:44 PM There was no evidence that a provider had assessed Patient #1's psychiatric, physical, and social functioning on 10/19/2022, the date of discharge.

On 1/27/2022 Patient #1 was admitted again under Chapter 51 (involuntary admission) for medication adjustment when he became agitated, "punched a correctional officer," and was "noted to be responding to active internal stimuli." He was treated and discharged on 2/08/2022. His discharge summary was dated 3/11/2022 at 4:43 PM. There was no evidence that Patient #1's psychiatric, physical, and social functioning were assessed 2/08/2022, the date of discharge.

Review of Patient #8's medical record revealed Patient #8 was admitted 1/18/2022 under an emergency detention for thoughts of harming himself. He was treated and discharged on 1/28/2022. His discharge summary was dated 2/09/2022 at 3:05 PM and co-signed by Medical Director J on 2/10/2022 at 2:37 PM. There was no evidence that Patient #8's psychiatric, physical, and social functioning were assessed on 1/28/2022, the date of discharge.

On 5/04/2022 between 9:45 AM and 1:47 PM, during interview with Health Information Supervisor (HIS) P, while reviewing Patient #1's medical record, HIS P stated there was no documentation by a provider on 10/19/2021 or 2/08/2022, the dates of discharge.

On 5/04/2022 at 4:40 PM during interview with Health Information Supervisor (HIS) P, while reviewing Patient #8's medical record, HIS P stated there was no documentation by a provider on 1/28/2022, the date of discharge.

On 5/05/2022 at 8:20 AM during interview with Medical Director J, Director J stated that the patient's psychiatric, physical, and social functioning were assessed by the provider on discharge and documented in the discharge summary under the Mental Screening Exam. When asked if it was expected that the provider would have seen Patient #1 and Patient #8 the day of discharge, Director J stated "there should be a MSE (mental screening exam) documented on each patient on the day of discharge."